Author: Michelle Rice, RN, MSN, CWOCN, Duke University Hospital, Durham, North Carolina.
Fig 1: First visit May 15th, 2007Clinical Picture
We were presented with a patient with the following details:
- 13-day old, 1410g neonate
- 30-week gestation twin
- Necrotizing enterocolitis x 4 days with perforation
- SBR, ileostomy and mucous fistula
- Flush stoma
- Budded mucous fistula
- Nurses were unable to pouch the patient at all using Ilex ointment and gauze dressings.
The child was experiencing significant peristomal skin breakdown, largely due to an inability to maintain pouch seal. Inconsistent care from staff was also proving problematic, all of which resulted in significant pain for patient.
Fig 2: 2nd Visit on May 16th, 2007
First goal of care plan
Considering the problems that the child had, we felt that healing skin breakdown was the first issue that needed attention as this was the main reason for the patient’s pain and also needed to be addressed before considering pouch weartime.
What is the most likely cause of the patient’s peristomal breakdown?
The general causes for peristomal breakdown would be:
- Fungal rash
- Irritant contact dermatitis
- Staph infection
- Allergic contact dermatitis
In this case, skin breakdown was as a result of irritant dermatitis as skin damage was occurring due to a failure of the pouch seal that allowed prolonged contact with urine or stool.
The second goal of care plan
Before considering other issues such as education for parents, teaching for NICU staff on use of the system, etc the second most important issue that needed to be addressed was increasing the pouch wear time.
The best course of action
We found that the best course of action was to apply pectin-based powder, alcohol free skin sealant and a convex pouching system with a belt.
Fig 4: Eakin Cohesive Seal in place
Fig 3: Products usedWhat worked for us?
We found the following combination to be the best solution for our patient:
- Nu-Hope neonate pouch
- Nu-Hope convex insert
- Nu-Hope neonate belt
- Hollister newborn wafer
- Hollister closure
- Eakin Cohesive Seal
Fig 5: On May 17th, 2007
Final Plan of Care
- Visual instructions were left for the nursing staff
- Daily visits by Ostomy Nurse and prn were required
- Many bedside in-services for core nursing team and NNP’s
- Final wear time was 12-14 hours resulting in a pouch change each shift
- Stoma in June of 2007